Comprehensive Med Surg Exit Exam Latest Test Bank WITH RATIONALES

Comprehensive Med Surg Exit Exam Latest Test Bank WITH RATIONALES The nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. Which of the following measures would the nurse avoid in planning for the client's safety? ◦ A. Padding the side rails of the bed ◦ B. Putting a padded tongue blade at the head of the bed ◦ C. Placing an airway, oxygen, and suction equipment at the bedside ◦ D. Having intravenous equipment ready for insertion of an intravenous catheter - Answer-BPutting a padded tongue blade at the head of the bed Rationale: seizure precautions may vary from agency to agency but the generally have some common features. Usually an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if anticonvulsant medications must be administered. The use of padded tongue blades is highly controversial, and they should not be kept at bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking the airway from improper placement, chipping the client's teeth. The nurse is caring for the client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated? ◦ A. Loosening restrictive clothing ◦ B. Restraining the client's limbs ◦ C. Removing the pillow and raising padded side rails ◦ D. Positioning the client to the side, if possible, with the head flexed forward - Answer-B- Restraining the Client's Limbs Rationale: Nursing Actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising the side rails in the bed, and placing the client on one side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible protects the head from injury, and moves furniture that may injure the client. Other aspects of care are as described for the client who is in bed. The nurse is trying to communicate with a client with a stroke and aphasia. Which of the following actions by the nurse would be least helpful to the client? ◦ A. Speaking to the client a slower rate ◦ B. Allowing plenty of time for the client to respond ◦ C. Completing the sentences that the client cannot finish ◦ D. Looking directly at the client during attempts at speech - Answer-C- Completing the sentences that the client cannot finish. Rationale: Note that the question asks which is least helpful. These words indicate a negative event query and ask you to select an option that is and incorrect action. The client has experienced an episode of Myasthenic crisis. The nurse would assess whether the client has precipitating factors such as: ◦ A. Getting too little exercise ◦ B. Taking excess medication ◦ C. Omitting doses of medication ◦ D. Increasing intake of fatty foods - Answer-COmitting doses of medicatio